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 With the Regence and Wells Fargo Bank Healthcare Savings Account (HSA) program, you purchase a high deductible catastrophic major medical program through Regence BlueShield and set up a HSA with Wells Fargo Bank. There are no primary-care gatekeepers on the Regence BlueShield medical plan and you have the freedom to see specialists without referrals via their State wide PPO network. Regence BlueShield offers a $2,500 individual deductible or a $5,000 family deductible medical plan and you have the option to make contributions to the HSA in amounts equal to the deductible you choose.
Benefit Summaries:
Rates:
Providers:
Enrollment:
Eligibility
To be eligible you must not be eligible for Medicare and be a resident of one of the following counties; Clallam, Columbia, Cowlitz, Grays Harbor, Island, Jefferson, King, Kitsap, Klickitat, Lewis, Mason, Pacific, Pierce, San Juan, Skagit, Skamania, Snohomish, Thurston, Wahkiakum, Walla Walla, Whatcom or Yakima. Proof of residency must accompany your application, such as a Washington State driver’s license or a current utility bill, with your name and address clearly visible.
Eligible dependents include your spouse and children under age 23 who are primarily dependent upon you for support. Dependents age 23 or older may apply as members for their own plan coverage.
Need Help? 206.448.7878 or 800.987.8199
Enrollment Forms & Instructions
Completed enrollment materials must be received in our office on or before 20th of the month to be effective on the first of the following month (e.g., June 20th for July 1st effective date).
- Complete the Regence’s Enrollment Application form and be sure to include proof of residency information as requested. Only one application is necessary per family and we recommend that you complete the Regence EFT Form so that premium payments are not missed by accident.
- Complete Wells Fargo HSA Setup Form and a check made payable to Wells Fargo for $100. The HSA Direct Deposit Form should be completed if you wish to have reimbursement automatically deposited into you bank account.
- Complete the Standard Health Questionnaire. A separate questionnaire must be completed for each enrolling family member unless:
- COBRA: The applicant has exhausted all COBRA or other continuation coverage. A copy of a HIPAA Certificate from the prior carrier is required.
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- PROVIDER CANCELLATION: The applicant’s provider has left his or her prior plan’s network and is in this plan’s network.
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- RELOCATION: The applicant has relocated within Washington State and the applicant’s prior plan is not available in the applicant’s new location.
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- An individual losing group coverage through their employer and is not eligible for COBRA does not have to complete the Standard Health Questionnaire if they’ve had 24 months of uninterrupted active group coverage and apply within 90 days of specific qualifying events. (After June 10, 2004)
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- An individual losing coverage due to the cancellation of their group conversion plan does not have to complete a Standard Health Questionnaire. (After June 10, 2004)
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The applicant must apply within 90 days of relocation, provider cancellation, or exhaustion of COBRA in order to have the Standard Health Questionnaire requirement waived. |
- Submit your Enrollment Application, Standard Health Questionnaire, and Proof of Residency to:
Your Enrollment Application and Standard Health Questionnaire must include an original signature (faxed copy is not acceptable).
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